胆道狭窄是肝移植术后的常见并发症,根据狭窄发生部位不同可分为吻合口胆道狭窄和非吻合口胆道狭窄。这两种类型的胆道狭窄危险因素、治疗方法和预后并不相同。现结合国内外文献,分别就肝移植术后两种类型胆道狭窄的危险因素和治疗进行综述。

Biliary strictures are the most common complications after liver transplantation and can be classied as anastomotic strictures (AS) and nonanastomotic strictures (NAS), according to the different location of the strictures. The two types of biliary strictures differ in pathology, risk factors, therapy, and prognosis. Combined with the literature at home and abroad, the risk factors and therapy of the two types of biliary strictures after liver transplantation are reviewed in this paper.

背景：肝移植后胆道并发症可引起移植后肝失功，超声是移植肝胆道并发症的重要检查手段之一。目的：探讨超声对肝移植后胆道并发症的诊断价值。 方法：纳入92例肝移植患者，男81例，女11例，年龄21-67岁；其中同种异体原位肝移植90例，活体部分肝移植2例；胆道重建方式均为胆管-胆管端端吻合。回顾性分析肝移植后常规检查及彩色多普勒超声检查结果，着重分析患者有无胆漏、胆道狭窄、胆泥或胆石形成，部分患者于超声引导下穿刺引流。 结果与结论：92例患者中超声诊断肝移植后胆道并发症14例：胆漏5例；胆道狭窄4例，其中吻合口狭窄2例，非吻合口狭窄2例；4例胆泥形成；1例胆管结石。提示肝移植胆道并发症患者有特征性超声表现，超声对肝移植后胆道并发症的诊断有重要价值。

BACKGROUND:Biliary complications after liver transplantation can cause liver graft dysfunction. Ultrasound examination is one of important diagnostic methods of biliary complications after liver transplantation. OBJECTIVE:To investigate the value of ultrasound in the diagnosis of biliary complications after liver transplantation. METHODS:A total of 92 patients after liver transplantation, including 81 males, 11 females, aged 21-67 years;al ogenic orthotopic liver transplantation in 90 cases, partial living liver transplantation in 2 cases. Biliary reconstruction methods were end-to-end biliary anastomosis. Routine examination after liver transplantation and color Doppler ultrasound results were retrospectively analyzed. The inspection focused on whether common bile duct and intrahepatic bile duct had biliary leakage, biliary stenosis, biliary sludge or biliary calculus. Some patients underwent puncture and drainage under ultrasonographic guidance. RESULTS AND CONCLUSION:In al the 92 pa

目的 探讨肝移植术后胆道非吻合口狭窄(NABS)的诊治流程.方法 回顾性分析近10年来我中心肝移植术后发生胆道NABS患者的临床资料,比较NABS的各种诊断和治疗方法,探讨其最佳诊治流程.结果 本中心403例次肝移植患者NABS总体发生率3.2％(13/403),其中心脏死亡供体捐献(DCD)NABS发生率4.16％ (2/48),两者比较差异无统计学意义(P＞0.05).NABS主要表现为胆红素、胆道酶谱升高及反复发作的胆管炎,与对照组(n=20)比较均差异显著(P＜0.01).全部患者经胆道造影确诊,并据此将NABS分为3型:围肝门部狭窄(Ⅰ型,4例);肝门部+肝内胆管狭窄(Ⅱ型,7例);肝内胆管多发狭窄(Ⅲ型,2例).本组NABS患者的治疗主要包括介入微创、胆肠吻合、再次移植3种方法.Ⅰ型患者均通过介入微创和胆肠吻合治愈,但有44.4％ (4/9)的Ⅱ型和Ⅲ型患者需要再移植治疗.再移植后死亡1例,余12例疗效满意,总有效率92.3％(12/13),治疗后随访12例患者胆红素及胆道酶谱均明显下降(P＜0.05).结论 胆道非吻合口狭窄是肝移植术后一种常见的胆道并发症,胆道造影是诊断的金标准.根据胆道造影显现的狭窄类型,遵循从简单到复杂的流程,选择介入微创、胆-肠吻合或再移植手术.Ⅰ型患者相对处理简单,预后最佳,Ⅱ型及Ⅲ型患者若介入微创

Objective To study the diagnosis and treatment of non-anastomotic biliary stricture (NABS) after liver transplantation.Methods The clinical data of 403 patients who underwent liver transplantation in the past 10 years in our department were analyzed retrospectively,compared different methods to find out the most appropriate method in the diagnosis and management of NABS.Results NABS occurred in 13 out of 403 patients (3.2％),almost the same incidence as in patients who received DCD donor livers (4.16％,2/48).The clinical signs of NABS were frequent cholangitis and high TBil,r-GT and AKP (P ＜0.01).All these cases were finally diagnosed by cholangiography and they could be classified into 3 types:hepatic bile duct stricture (4 patients,type Ⅰ),multiple extrahepatic and intrahepatic biliary strictures (7 patients,type Ⅱ),intrahepatic biliary strictures (2 patients,type Ⅲ).NABS were mainly treated by interventional therapy,Roux-en-Y anastomosis and retransplantation in our ce

目的探讨胆道镜直视下微波治疗胆管壁病变的效果。方法在胆道镜直视下对胆管壁病变71例(包括胆管狭窄、胆管息肉、胆管息肉样病变、胆管壁肿瘤)进行微波治疗:(1)对胆管狭窄采用微波功率50~90 W,多点多次放射状凝灼、切开,使膜样增生的组织炭化或汽化,狭窄口扩大;(2)胆管息肉、胆管息肉样病变及胆管肿瘤先取活检,采用功率90~110 W,直视下将辐射头插入病变实质内,使病变局部发白炭化。结果 (1)胆管狭窄微波治疗33例次37处,治疗后胆管狭窄均有好转,原有嵌顿的结石被清除;T管造影检查,原不显影的胆管分支显影良好或较前改善。(2)胆管息肉及息肉样病变、胆管壁肿瘤44例次47处,经微波治疗后,所有胆管壁病变均消失或基本消失。胆道镜复查或影像学检查未见复发。(3)所有病例术后无明显出血、穿孔等并发症发生。胆道镜无损坏,图像显示仍良好。结论应用微波技术经胆道镜直视下微波治疗胆管壁病变,充分利用了微波技术和胆道镜技术两者的优势,扩大了胆道镜技术与微波技术的应用范畴,且操作安全、疗效确切,值得临床推广。

Objective To explore the effect of microwave technique under choledochoscope for treatment of bile duct wall diseases .Methods Seventy-one patients with bile duct wall disease ( bile duct stricture , bile duct polypi, polypus-like pathological changes of bile duct , bile duct tumor) were treated with microwave technique under choledochoscope .The power of microwave for treatment of bile duct stricture was 50~90 W.The stricture sites were enlarged by multi-points coagulation and rad cauterization to char or gasify the membrane-like hyperplastic tissues . For treatment of bile duct polypi , polypus-like pathological changes of bile duct and bile duct tumor which first under -went biopsies to rule out cancerization , the power of microwave was generally 90~110 W.During the operation , the radiation head was usually inserted into polypi foci to make local tissue white -looking and charring then .Results To-tally 37 sites in 33 cases of bile duct stricture and 47 sites in 44 cases of bile d

目的：探讨肝移植术后缺血性胆道病变（ITBL）患者接受介入治疗的安全性及疗效。方法回顾性分析2006年1月至2014年2月在中山大学附属第三医院介入血管科接受介入治疗的76例肝移植术后ITBL患者的影像及临床资料。按胆道造影表现分为3组：肝门区狭窄组（28例），肝内多发狭窄组（42例），胆汁瘤组（6例）。治疗方式包括单纯经皮经肝胆管引流术（PTBD ）、PTBD配合球囊扩张、PTBD配合球囊扩张及胆道内支架术。引流方式包括胆道外引流及胆道内外引流。术后随访并观察疗效及胆道并发症。结果76例患者的PTBD首次成功率为97％（74／76）。介入治疗的总体治愈率、好转率及无效率分别为21％（16／76）、51％（39／76）、28％（21／76）。其中，肝门区狭窄组治愈10例（36％），好转16例 （57％），无效2例 （7％），治疗有效22例 （93％）；多发性狭窄组治愈6例 （14％），好转21例（50％），无效15例（36％），治疗有效27例（64％）；胆汁瘤组好转2例 （2／6），无效4例（4／6）。肝门区狭窄患者的疗效优于多发性狭窄患者（P＜0.05），多发性狭窄患者的疗效优于胆汁瘤患者（P＜0.001）。引流管期间主要并发症为胆道感染，其中外引流及内外引流胆道感染发生率分别为20％（13／64）及67％（8／12），比较差异有统计学意义（P＜0.001）。结论 PTBD是治疗肝移植术后ITBL的安全、有效手段之一。结合球囊扩张及内支架置入可有效改善患者症状，提高生存质量。采用胆道外引流可显著降低胆道感染发生率。

Objective To investigate the safety and efficacy of interventional treatment for ischemic-type biliary lesion (ITBL)after liver transplantation (LT). Methods The clinical and imaging data of 76 patients with ITBL after LT,who received interventional treatment in the Department of Interventional Vascular Radiology of the Third Affiliated Hospital of Sun Yat-sen University from January 2006 to February 2014,were retrospectively analyzed. On the basis of the cholangiographic appearance,patients were classified into 3 groups:hilar biliary stricture group (n=28),multifocal biliary stricture group (n=42),and biloma group (n=6). The modalities of interventional treatment were percutanous transhepatic biliary drainage (PTBD), PTBD combined with balloon dilation,PTBD combined with balloon dilation and plastic stent implantation. The methods of biliary drainage included external drainage and external-internal drainage. All the patients were followed up after treatment. The curative eff